Provider Demographics
NPI:1093947913
Name:ELLIS, HEATHER SHANNON STOUME (MSW, P-LCSW, LCAS,)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:SHANNON STOUME
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MSW, P-LCSW, LCAS,
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:STOUME
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:910-343-0145
Mailing Address - Fax:910-251-5324
Practice Address - Street 1:120 COASTAL HORIZONS DR
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-6094
Practice Address - Country:US
Practice Address - Phone:910-754-4515
Practice Address - Fax:910-251-5324
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1471101YA0400X
NCC0066161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)